ESRI Geomedicine

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Geomedicine

Geography and Personal Health

Bill Davenhall, Esri

August 2012


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2GeomedicineGeography and Personal Health August 2012

3 Introduction

3 What Is Geomedicine?

3 What Is GIS?

4 The Missing Link

4 Geography and Personal Health

6 Improving Personal Health and Saety

7 A Road Map to Better Health

10 Answering Questions

10 What Can Your Address Reveal about Your Health?

12 Are There Toxins in Your Home?

13 Are There Toxic Chemicals in Your Community?

14 Is Your Local Water Supply Sae?

15 Do You Live in a Food Desert?

18 Geomedicine at Work18 The Geography o Cancer

19 Mapping Breast and Prostate Cancer Patterns

20 Busy Roads, Air Pollution, and Environmental Health

Risks

23 Does the Environment Really Matter to Your

Health?

23 GIS and Global Health

25 Evaluating Geomedicine

27 The Future o Geomedicine

29 Bibliography

31 Acknowledgments

31 About the Author

31 About Esri

Table of Contents


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3IntroductionGeomedicineGeography and Personal Health August 2012

Linking ones own personal health status to specic geographic

actors provides a powerul set o inormation that medical

proessionals can use to improve the quality o the care they

deliver. In this e-book, I set orth the notion that the emerging

eld ogeomedicine will produce a new type o medical

intelligence that will leverage national spatial data inrastructures

to benet personal human health.

What Is Geomedicine?

At the present time, very lit tle health-relevant geographic

inormation is available to a clinician at the time o a medical

diagnostic encounter, and it is certainly not a typical part o

a comprehensive medical record. Geomedicine uses modern

inormation technology to deliver inormation on a patients

potential environmental exposures into the hands o the clinicianwhile they are in the examination room.

With geomedicine, we will experience an increase in the

number o patients who benet rom a more precise clinical

understanding o the links between their health and where they

live, work, and play.

What Is GIS?

Geographic inormation system (GIS) technology integrates

hardware, sotware, and data or capturing, managing, analyzing,

and displaying all orms o geographically reerenced inormation.

GIS allows us to view, understand, question, interpret, and

visualize data in many ways that reveal relationships, patterns,

and trends in the orm o maps, globes, reports, and charts. GIShelps us answer questions and solve problems by looking at data

in a way that is quickly understood and easily shared.

GIS has long been used to monitor the health o the planet.

With geomedicine, GIS is now being used to monitor the health

o individuals. It makes sense, because the health o people

depends on the heath o the planetand thats the basic idea

behind geomedicine.

Introduction
http://www.esri.com/industries/health/geomedicine/index.htmlhttp://www.gis.com/http://www.gis.com/http://www.esri.com/industries/health/geomedicine/index.html


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4The Missing LinkGeomedicineGeography and Personal Health August 2012

The Missing Link

Geography and Personal Health

In 2001, I was hit by a train. Not a real trainbut it might as well

have been! My train was a heart attack. When it happened, I

thought, Why me? Why now? Why here?I thought I was in good

health. I had ollowed the advice o many doctors, but still the

train had hit me. As I worked through my crisis, I started thinking

about the many actors that could have contributed to my heartattack and wondered why I had not had better warning.

Having worked in and around health care or many years, I had

learned a great deal about how to avoid a heart attackyou

know, the usual things: avoid risks, live a healthy liestyle, control

my weight, choose better ood and drink, dont smoke, reduce

stress . . . all excellent advice to a reasonable person.

Like many o you, I had provided a lot o personal inormation

to my health care providers over many years, such as amily,medication, surgical, disease, allergy, and social history as well

as my liestyle inventory. I now wondered why none o that

inormation had actually helped prevent the roaring train bearing

down on me.

I soon began to discover that there were many dierent reasons

why I may have been hit by that train. In addition to all the

usual suspectshigh blood pressure, high cholesterol, stress,

geneticsI discovered that many environmental conditions and

exposures could greatly increase my risk o a heart attack, things

like air quality and exposures to pollutantssome that I did not

even know existed in the communities where I lived. As I began

to research the places where I had lived both as a child and an

adult, I began to discover disturbing inormation on what Iand

my doctorscould have already known about the quality o myWatch my presentation Your Health Depends on Where You Live romTEDMED 2009.
http://www.ted.com/talks/lang/en/bill_davenhall_your_health_depends_on_where_you_live.htmlhttp://www.ted.com/talks/lang/en/bill_davenhall_your_health_depends_on_where_you_live.html


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GeomedicineGeography and Personal Health August 2012 5The Missing Link

various environments and what the impact may have been on my

health.

My search was not easy, even with use o the Internet. Large

volumes o health inormation were spread across many

governmental and health-related websites o varying quality.

While I cannot prove that any specic environment caused my

heart attack, there was plenty o evidence that some o the

contaminants I had been exposed to in places where I hadlived were well-known precursors to circulatory and respiratory

diseaseand, yes, heart attacks. It was at this moment that

I realized that a physician looking at my health history, in

the absence o any specic inormation about my unique

environmental exposures, would be less likely to warn me, let

alone guide me away rom the oncoming train wreck. The

problem, as I have come to see it, is that none o my physicians

had a useul or easy way o translating all that rich environmentalhealth research into something that would directly benet me.

Why was it so dicult or me and my doctors to connect the

dots?

Every place I have ever lived is part of my medical history.

The impact o breathing bad air in many o the places I have lived

will surely ollow me wherever I go; thereore, my medical record

should be automatically inormed about new research ndings o

relevant health risks.

Unortunately, today my medical recordand probably yours as

wellis already a vast collection o clinical acts, observations,

test results, and diagnostic conclusions but remains silent about

the accumulation o environmental health impacts and risks. As

both a patient and a good-health-seeking consumer, I need to

be better served by the great wealth o environmental health

Heart attack rates, the Environmental Protection Agency (EPA) ToxicsRelease Inventory, and other inormation can show links between yourhealth and where you have lived.

(Copyright Esri and the Trustees o Dartmouth College)


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GeomedicineGeography and Personal Health August 2012 6The Missing Link

research that is available. I also need to do what I can to increase

the ability o physicians to consume and use this inormation in

smarter ways.

I invite you to think about the places youve lived or where

you live today, and learn more about the impacts o your

environments on your own health. Think about how you might

approach your own health discovery process. There is much to

learn about geomedicine and how it can become a valuable

tool in clinical practice. I hope this discussion o geomedicine is

the beginning o your personal journey to discover ways to stay

healthy longer.

Improving Personal Health and Safety

There is abundant evidence that the use o geographic

inormation has had a dramatic impact on the work o health

proessionals. Medical epidemiologists, the ront line o disease

detectives, have used GIS extensively in their ght against

diseases that have a clear relationship between person, place,

and time. GIS has also played an important role in protectingcommunities rom otherwise overlooked risks and toxic

exposures.

Geomedicine applies the power o GIS technology to personal

health. As this concept continues to be adopted by more health

care proessionals, physicians will increasingly use geomedicine

to help diagnose, treat, and prevent illness and, in some cases,

even make recommendations to patients on where they might

live, work, and play.

A trajectory density map o the Aiken area in the state o SouthCarolina shows high ozone days.


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Health care accreditation and oversight bodies have also

expressed interest in redening the geographic scope o patient

saety, encouraging health care providers to consider the value

o integrating internally generated health care inormation withexternally available population health inormation. Principal

drivers or such a redenition o quality care and patient

saety include the impacts o unintentional toxic exposures,

compromised environmental conditions, unexpected situational

dangers, untoward outcomes, medical misadventures (during or

ater clinical care), and the lack o timely logistical inormation or

distributing health proessionals and dispensing medical supplies.

The persistent and unmistakable convergence o two powerul

orcespersonal human health actors and environmental

conditionscontinues to drive geomedicine orward. Using GIS

to deliver geomedical intelligence to health care practitioners

could prooundly alter the way providers view patient saety and

quality o care.

A Road Map to Better Health

What do Hippocrates and Dr. Ethan Berke have in common?

For starters, each chose to be a physician. Despite 2,400 years

dierence in their agesHippocrates, o course, lived in about

400 BC and Berke lives in the presentthey both understood the

direct connection between the places in peoples lives and their

respective impact on personal health. Hippocrates and Berke

both concluded that your health depends on the air you breathe,

the water you drink, and the environment in which you live. In

act, Berke believes that geography matters in personal health,

and so do many o his colleagues in amily medicine.

Berke suggests that place is another useul vital sign to any

primary care physiciansomeone who is concerned about the

whole patient. This belie that our places are actually another

vital sign is not so hard to grasp when he suggests in the Journal

o the American Board o Family Medicine, Recommendations

Assessing Levels o Perchlorate Contamination in the Water Supply(Perchlorate is a chemical associated with thyroid disease and cancer.)
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3174470http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3174470http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3174470http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3174470



made in the clinical setting pertaining to healthy liestylesmore

activity, better diets, avoidance o potential toxins or pollutants

cannot occur in a vacuum. I our patients are in a home or work

environment that does not give them the opportunity to heedour recommendation, their chance o success will be diminished.

Strong words, but good advice!

Here is where I am on the same page with Hippocrates and

Berke: where a person has lived must be considered as part o

the context in which clinical decision making occurs. I would add

that increasing the transparency and utility o the inormation on

which physicians make recommendations and with which patients

are encouraged to comply could change the way we all go about

partnering with our personal physicians. So the next time you

say, There is no place like home, think about its environmental

context. The relationship we all have with our home, regardless

o its amenities, is unique and potentially harmul to our health

because o where that home is located geographically (and

perhaps what products were used in its manuacture).You dont have to look very ar to nd the evidence on this

subjectjust keep reading. While we are typically introduced

to our rst home shortly ater birth and without a choice, ourpersonal and local environment either enhances or diminishes

our start in lie in many dierent ways. So our chances o success

in achieving lielong health and wellness are deeply connected

to the places we spend those early years. O course, adults can

control many aspects o their local environments. We can choose

not to smoke or cook over open indoor fames and to use indoor

sanitation. But children never get that choice.

This map helps in understanding population density in relation to vaccinedistribution centers.



A child has to trust someone else (like parents and governments)

to protect our air; water; soil; and, in some cases, exposure to

things that can harm us. This is a big responsibility! You probably

have your own story about geomedicineunusual healthsymptoms that cant be explained; cancers that run in certain

amilies, neighborhoods, or communities; or the onset o chronic

conditions that dont appear to have a genetic or liestyle link.

Suddenly people start to pay attention to whats around them,

searching or anything that might help discover a cause or oer

relie or a cure.

Much like a mountain stream has headwaters, so does personal

health. Many will say that genetics is our health headwaters,

but as the stream meanders across many dierent geographic

landscapes, so does our health, accumulating unseen exposures

and acing uncertain and not very apparent risks. The application

o geomedicine, then, is about translating what we know about

illness and disease, and what we understand about the role

that our various environments play in making us sick (or well),

into practical inormation that allows each o usphysician or

consumerto make better choices about where we live and how

we engage with our environment.


10/3310Answering QuestionsGeomedicineGeography and Personal Health August 2012

Answering Questions

What Can Your Address Reveal about Your Health?

Health and medical literature is lled with thousands o studies

that link poverty to health status, especially among children

and young adultsa preponderance o evidence suggests that

a poor start in lie is a major health determinant. Poverty is

not evenly spread across ethnic, racial, or demographic groups,

nor is poverty just about how much money people have at theirdisposal. Sometimes the impact o poverty on health is subtle,

such as low-perorming public schools with high truancy and low

graduation rates, all contributing to poor health.

A good example o what I am talking about is the school

perormancewebsite created by the Washington Postthat

provides public access to the Washington, DCs public school

scorecards, including their physical and structural adequacy,

health violations, and availability o qualied teachers. Ieducation is a marker or the uture health o our children, then a

physicians knowing more about the likely educational outcome

or a child might inorm treatment decisions and ultimately impact

a prognosis. Another good example o this type o street address

discovery is the New York City Mayors Oce website that

contains a neighborhood statistics interactive web application.

I you live in New York City, you can enter your street address

and get a wealth o inormation about what is happening in your

neighborhood, rom public health and saety to education and

community resources.

Much like a blood test provides useul clues to underlying health

problems that doctors cant always see at the surace, your

street address can also provide valuable contextual inormation,medically speaking. This is possible because o a vast system

o linked data rom the US Census Bureaus enumeration

program. This program helps market research organizations

better understand what is happening around yourom retail

transactions at your local pharmacy to what you and your

neighbors like to eat and watch on TV. Specic knowledge

about the composition o and likely behaviors hidden within

your neighborhood is unlocked when you provide your physicianwith your street address. A physician advising a patient to eat

more resh ruits and vegetables when there is no grocery store

oering these oods within a reasonable distance will probably

result in a noncompliant patient.

My argument is straightorward: physicians do not use, or clinical

purposes, all the inormation that patients, like me, routinely
http://www.washingtonpost.com/wp-srv/metro/interactives/dcschools/scorecard.htmlhttp://www.washingtonpost.com/wp-srv/metro/interactives/dcschools/scorecard.htmlhttp://www.washingtonpost.com/wp-srv/metro/interactives/dcschools/scorecard.htmlhttp://gis.nyc.gov/ops/mmr/address.jsp?app=MMRhttp://gis.nyc.gov/ops/mmr/address.jsp?app=MMRhttp://www.washingtonpost.com/wp-srv/metro/interactives/dcschools/scorecard.htmlhttp://www.washingtonpost.com/wp-srv/metro/interactives/dcschools/scorecard.html


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provide (such as street address); they rely only on what they

observe and receive in the standard examination. My street

address, however, contains important clues about my economic

and social contextclues that could help my physician diagnose,treat, and advise me. In act, my physician could know most o

this about me even beore I walk through the exam room door!

The challenge o equipping my doctor with useul, geographically

relevant inormation is great. My physician recently suggested

to me that she would have little time or making assessments

o such nonclinical inormationjust something else to clutter

up my charts, and more importantly, I have not been trained to

understand how to use it. And she is rightphysicians in the

United States dont have adequate inormation delivery systems

or medical training experiences that help them learn how to

leverage this type o inormation. This is where geomedicinecomes into play, by creating new ways to see the patients

surrounding environmentboth as it is now and as it was in

the past. Accessing and using data that adds intelligence to

the medical encounter should be the driving orce behind

modernizing our health inormation technology.

When it comes to my health, I want my doctors to use all the

inormation I provide to themnot to be guessing about my

ability to ollow their instructions and seek recommended

treatments and therapies. I want them to be acutely aware o my

potential ability in ollowing through with their advicephysically,

culturally, and economically. The practice o gleaning valuable

inormation rom something as simple as my street address has

been around or decades, yet medicine has ailed to incorporate

it into my medical record in useul ways.

I believe its time we help health care proessionals do thisby building into their medical inormatics technologies better

ways to link to rich data that adds new value. The tidal wave o

personal health data that is headed to our doctors oces as

the result o real-time biomedical and environmental monitoring

sensors leaves medicineand my own physicianlittle choice

but to attempt to harness these new data streams to benet my

personal health.

Elkhart County, Indianas Whats In My Back Yardapplication gives the public access to inormation orevaluating potential health risks in their communities. Thismap shows leaking underground storage tanks (red dots)

and Toxics Release Inventory sites (green squares).
http://www.esri.com/industries/health/geomedicine/index.htmlhttp://www.esri.com/news/arcwatch/0910/elkhart-brownfields.htmlhttp://www.esri.com/news/arcwatch/0910/elkhart-brownfields.htmlhttp://www.esri.com/news/arcwatch/0910/elkhart-brownfields.htmlhttp://www.esri.com/industries/health/geomedicine/index.html


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GeomedicineGeography and Personal Health August 2012 12Answering Questions

Are There Toxins in Your Home?

Did you grow up in a house that was built beore 1978? One

progressive community aairs department is linking geographic

inormation to potential environmental health-risk inormation to

help protect young children. I you are pregnant or have children

or grandchildren younger than six years o age who will spend

any signicant time in a house built beore 1978, then read on!

Beore my sixth birthday, I had already lived in several houses

that were built long beore 1977, when the US Environmental

Protection Agency ban on lead in paint took eect. This means

that I am among millions o people who were most likely exposedto unhealthy levels o lead. Most o the lead in my blood

probably came rom simple things most children dolicking or

chewing the painted suraces o tables, walls, staircase railings,

doors, window casings, and toysor rom breathing lead dust

generated by sanded or chipped paint containing lead.

I am certainly not alone in having ingested more than a air share

o lead during my rst six years o lie. Decades later, public

health departments around the world are still on an aggressivemission to get rid o this toxic material, particularly rom the

bodies (and blood) o young children. There are many products

that allow lead to get into the blood o a child (e.g., water pipes,

cosmetics, imported candies, cooking utensils, painted toys, and

dust rom making handcrats). Public health experts go as ar as

to warn that pregnant women should not remain in a house built

This map shows predicted ozone concentration in the state o SouthCarolina.


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beore 1978 that is undergoing remodeling, where old paint may

be sanded and dust is not contained.

At last count, more than a quarter o a million children aged one

to ve years in the United States alone have unacceptable blood

lead levels that are leading to learning disabilities and behavioral

problems and, when at very high levels, seizures, coma, and

even death. The State o New Jersey Department o Community

Aairswebsite allows you to check a dwelling address online to

see i lead contamination has been detected or is in the process

o being cleaned up. In some cases, you can even nd out i its a

lead-ree dwelling.

Websites such as this, I strongly believe, are the beginning o

the response to the publics demand or environmental health

transparency. Such websites usher in a whole new dose o public

empowerment. This site validates the notion that geomedicines

chie contribution will be to help people connect the dots and

take health knowledge to the next level by linking the whatto

the where and when at the household level, since this is where

much o the clinical knowledge and environmental health impactsbecome relevant to each o us.

Are There Toxic Chemicals in Your Community?

Over the past several years, I have visited numerous websites and

used a number o applications created by government agencies,

newspapers, health research organizations, and others, that are

intended to help us better understand our local environments

rom water quality and lead poisoning in children to school

conditions and local cancer cases. These services help people

nd out more about the places they live and see the connectionsbetween public health issues and their own personal health-

seeking interests, embarking on a journey o geomedical sel-

discovery.

One o these ree services is an application that allows you to

enter the street addresses o all the places you have lived or

worked within the United States. Ater entering your addresses,

you can create a report listing exactly what toxic chemicals are

Using the Explore Your Place History application, you can view heartattack rates, the US EPAs Toxics Release Inventory, and more, or areaswhere youve lived and worked.
http://www.cdc.gov/nceh/lead/http://www.cdc.gov/nceh/lead/http://www.njleadsafe.info/http://www.njleadsafe.info/http://www.njleadsafe.info/http://www.esri.com/industries/health/geomedicine/map.htmlhttp://www.esri.com/industries/health/geomedicine/map.htmlhttp://www.njleadsafe.info/http://www.njleadsafe.info/http://www.cdc.gov/nceh/lead/http://www.cdc.gov/nceh/lead/


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close to your places. You can access the place history application

using a web browseror download the application or youriPhone

or iPad.

What makes this application unique? While the US EPA and

the National Library o Medicine (NLM) have sites that provide

citizens access to data about hazardous chemicals, neither allows

building, exploring, saving, or sharing a lietime place history.

I believe that having a geographically accurate place history,

maintained and controlled by consumers, can help inorm us

and our health care providers about the potential environmental

health burdens we all accumulate over a lietime. As newlocal health data is published at smaller levels o geography,

consumers can come to expect their place history to reveal a

wide range o useul inormation suitable or sharing with their

amily and their doctors.

In the initial release o the place history application, the locations

o the Toxics Release Inventory rom the US EPA were mapped

against a background showing the death rates or heart attacks

in people enrolled in Medicare. I would encourage you to createyour own place history and see what you discover. Please also

take the time to read the About section o the place history

application to learn more about the limitations o the data.

Is Your Local Water Supply Safe?

Unlike all the other nutrients we ingest, water is mandatoryno

one can live very long without consuming a certain amount o

water on a regular basis. While there is expert medical debate on

how much water a person actually requires daily, it is clear that

without a reliable supply o clean drinking water, our personal

health is surely compromised. Finding inormation about the

quality o your drinking water is not an easy task unless, o course,

you already know what you are looking or. It also helps to be a

chemist! Iyou cant nd this data easily, do you think your doctor

would have any better luck?

I would wager that there is not much water quality inormation

in your medical record unless, o course, you have been treated

or waterborne disease. Most o us who live in the United States

dont give water quality a second thoughtbut you might be

surprised to learn how water quality varies rom city to city.

University o Cincinnati has a very useul and simple-to-use

application that shows the water quality or metropolitan

areas across the United States. The site allows visitors toidentiy metropolitan areas in the United States and discover

concentrations o selected chemicals as well as the presence

o biologic pathogens occurring in the drinking water o these

communities. In many parts o the United States, specic harmul

chemicals may dominate a regions drinking water supplies;

thus, a physician would be expected to understand what these
http://itunes.apple.com/us/app/my-place-history/id396902848?mt=8http://www.esri.com/industries/health/geomedicine/map.htmlhttp://appshopper.com/healthcare-fitness/my-place-historyhttp://appshopper.com/healthcare-fitness/my-place-historyhttp://www.epa.gov/tri/trichemicals/chemicallists/RY2009ChemicalList.pdfhttp://www.uc.edu/gissa/projects/drinkingwater/http://www.uc.edu/gissa/projects/drinkingwater/http://www.uc.edu/gissa/projects/drinkingwater/http://www.uc.edu/gissa/projects/drinkingwater/http://www.epa.gov/tri/trichemicals/chemicallists/RY2009ChemicalList.pdfhttp://appshopper.com/healthcare-fitness/my-place-historyhttp://appshopper.com/healthcare-fitness/my-place-historyhttp://www.esri.com/industries/health/geomedicine/map.htmlhttp://itunes.apple.com/us/app/my-place-history/id396902848?mt=8


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dierences in water quality could actually mean or diagnosing a

particular health problem.

In spite o all the state and ederal agencies charged to measure

and report on the quality o our drinking water, I could only nd

one national-level websitethe New York Timessitethat led

me to actual water-quality testing data or my city. While the

EPA website has a great deal o useul inormation, it was more

challenging to discover an actual water quality report or my

community. I also know that many local communities provide

consumer-riendly water quality reports to their citizens, but an

interactive website that allows me to compare my citys water

quality to another city somewhere else in the United States

would be o great value, especially i I am thinking o moving

or evaluating the impact o water quality on a specic health

problem I am experiencing.

I youre like me, you have lived in more than one house and

probably ingested drinking water without knowledge o its

quality (other than its color, taste, or smell). I am certain that the

tap water I drink and use in ood preparation is as important tomy health as a lot o other, less conspicuous threats.

Geomedicine is all about connecting environmental inormation

to our personal health and, more importantly, encouraging our

personal physicians to use more o this type o inormation as

they work with us to nd answers to our health problems. I I am

careul enough to live to see my ninety-th birthday, I will have

consumed about 3 billion drops o drinking waterabout 33,000

gallons, or about 124 tons. Anyway you calculate it, thats a lot o

any substance going into anyones body, and its certainly worth

taking an interest in its quality.

Do You Live in a Food Desert?

To me, better health means eating better and getting enough

exercise. Grocery shopping is something most o us do at least

once a week. I recently heard a travel host talking about how

great it is to be close to three local bakeries, several butcher

shops, and hal a dozen local grocery stores within an easy

10-minute walk. O course, this travel host was talking about a

large European city; in the United States, most o us dont walk to

the nearest grocery storewe drive our cars.

When we do go to the grocery store, we may not even buy

wholesome oodslet alone resh ruits and vegetables. I

physical proximity to a grocery store stocked with wholesome

ood is critical to getting and staying healthy, then it is crucial or

us to nd a way to be assured that grocery stores are locatedwithin easy reachboth physically and nancially. Just as we

have come to recognize the need to treat unacceptable rates o

crime, poverty, or disease and the need or parks and sae places

to walk, we should also be considering access to wholesome,

quality ood at reasonable prices.
http://www.epa.gov/http://www.epa.gov/


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Food desertsare dened by the US Department o Agriculture

(USDA) as urban neighborhoods and rural towns without ready

access to resh, healthy, and aordable ood. These deserts are

essentially geographic places that lack reasonable access to agrocery store.

Reasonable is a relative term. The 20-something couple living in

an upstairs apartment in a large, urban environment may have no

problem running through city streets to buy groceries at a store

three miles away. However, the retired woman down the hall in

the adjacent apartment who had a hip replacement last year may

not have the stamina to walk more than a ew blocks with heavy

bags.

How many ood deserts are we talking about? According to the

USDAs Economic Research Service (ERS) report, more than

23 million Americans live within a ood desert, regardless o

whether they live in an urban or rural area. However, physical

access to ood or groceries can be dicult to measure due to the

many actors that create ood deserts.

To better understand the problem, two impressive web

applications were created to display the geographic locations

o ood deserts as well as provide estimates o the underservedpopulation by census tract:

USDAs Food Deserts Locator

Megacitys Food Desert Finder

These interactive maps may help increase the publics awareness

o the need to improve ood access as well as inorm real estate

developers and grocery store executives o the geographic

demands or better access to wholesome oods.

Johns Hopkins University Center or a Livable Future recently

studied Baltimores ood deserts as part o the Maryland Food

System Mapping Project. This study noted that although the

generally accepted description o a ood desert is a residential

area thats more than one mile rom a grocery store, supermarket,

or other ood vendor with a variety o resh ruit, vegetables,Megacitys Food Desert Finderincreases the publics awareness o theneed to improve ood access.
http://apps.ams.usda.gov/fooddeserts/foodDeserts.aspxhttp://www.ers.usda.gov/data/fooddesert/http://megacity.esri.com/fooddeserts/#-10523976.579302637;4721708.906047437;9http://megacity.esri.com/fooddeserts/#-10523976.579302637;4721708.906047437;9http://megacity.esri.com/fooddeserts/#-10523976.579302637;4721708.906047437;9http://megacity.esri.com/fooddeserts/#-10523976.579302637;4721708.906047437;9http://megacity.esri.com/fooddeserts/#-10523976.579302637;4721708.906047437;9http://www.ers.usda.gov/data/fooddesert/http://apps.ams.usda.gov/fooddeserts/foodDeserts.aspx


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dairy, and meat, most urban planners claim the acceptable

walking distance or public transportation is only a quarter mile.

Demonstrating the need or such tools, the Johns Hopkins study

used a quarter-mile walking distance combined with income datato account or lower-income households, which are unlikely to

have a car to drive to the nearest available ull-service grocery

store.

We all make ood-buying decisions based on personal preerence

and price, but i youre a working, single parent, are you really

going to carve out 45 minutes rom your evening to prepare

sauted salmon with vegetables and brown rice? Would you be

able to nd these oods in a corner convenience store? Throwing

a rozen pizza in the oven would be a much aster (and less

expensive) dinner solutionone thats readily available at most

street-corner stores.

It has become increasingly clear that where we live, work, and

play are intrinsically intertwined with our health and, thus, with

our ood choices. Our choice in what we eat is all too oten

infuenced largely by what we see and how hungry we actually

eel. Making it easier to see, touch, and purchase better ood

seems a worthwhile activity that we all can support.


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18Geomedicine at WorkGeomedicineGeography and Personal Health August 2012

Geomedicine at Work

The Geography of Cancer

Inspired by a bill introduced into the New York State Legislature

several years ago, the New York State Health Department has

liberated some powerul data about cancer incidences and

mapped it at the ZIP Code level. I you dont live in the state o

New York but still want to see the incidence o cancers in the

county where you live (there are 3,141 counties in the US), you canvisit the National Cancer Institutes website, where every state is

represented.

While presenting cancer data at this small geographic level is still

very new, the technology behind it is not. In act, I would expect

that as more people learn about this site, there will be a demand

or more inormation sharingsuch as cancer incidence rates,

more current population data to calculate rates, and interactive

graphs and charts to enhance the visitors overall experience.

Mapping our health geographically is a great opportunity or

a health department to begin educating the public in ways

that make sense to everyone and not just the needs o health

proessionals. The site, as you would expect, has several

important disclaimers and caveats that visitors are encouraged to

read. Nevertheless, knowing more about where cancers actually

Above is a map o Caliornia human papilloma virus(HPV) cases by outpatient diagnosis in each county. HPVinection is responsible or 99.7 percent o all cases ocervical cancer.
http://statecancerprofiles.cancer.gov/http://statecancerprofiles.cancer.gov/


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GeomedicineGeography and Personal Health August 2012 19Geomedicine at Work

occur is intriguing. This site engages us and eeds our sel-

discovery. You might ask yoursel why its taken governments so

long to realize the publics interest in looking at this type o data.

Linking geography to personal health using interactive mapping

technology at this more useul scale (such as ZIP Code and

census tracts in the United States) uels incredible curiosity

about the possible harmul exposures around the places we live

and work. It also provides a public window or seeing potential

environmental contamination in our communities. So, will we all

become citizen epidemiologists? Well, perhaps. This could

be similar to so many other areas o our society where we have

witnessed a deproessionalization o a complex eld. Maybe it s

healths turn?

Thanks to the Internet and the development o sotware

applications that demystiy complex processes and data

coupled with the publics interest in personal healthpublic

health agencies around the world will experience increasing

numbers o curious and tech-savvy health-seeking consumers

demanding much more health-relevant data delivered creatively

over the Internet. I you are like me, you will wonder why every

state does not make cancer data easily available.

Many people will take issue with the validity o exposing small-

area cancer data to the average citizen and showing at the

same time the exact locations o harmul chemicals regulated

by governments. I happen to believe that the more inormation

I have about the geographic incidence o cancer, the more

inormed I am as a health-seeking consumer. What about you?

Mapping Breast and Prostate Cancer Patterns

The emerging eld o geomedicine cant move ast enough or

many o us who ear the threat o cancerparticularly o the

breast or prostate. In a recently published study that used the

geographic microscope, as I like to reer to the geographic

analysis o disease, it was ound that the incidence o these two

cancers is not a random event. While the authors state that they

dont exactly know the underlying actors that cause these hot

spotsthe areas seen in red on the mapsthe analysis does

reveal the wide geographic variability in where people with these

types o cancer live. The maps are compelling because they

reveal distinct geographic patterns.
http://www.ij-healthgeographics.com/content/pdf/1476-072X-8-53.pdfhttp://www.ij-healthgeographics.com/content/pdf/1476-072X-8-53.pdf


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The authors suggest, and you can see or yoursel, that bothbreast cancer (map above) and prostate cancer (map below)

cluster geographically, with a strong northsouth distribution.

You can learn more about this study.

I I lived or more than a couple o years in any one o the red hot

spots, I would probably be more proactive in seeking requent

screenings or prostate or breast cancerwouldnt you?

More alarming to me, however, was the nding that in counties

with a high incidence o breast cancer, there was also a high

incidence o prostate cancer. The authors suggest that this is

happening because these two cancers might have similar or

common risk actors (e.g., the environment).

Busy Roads, Air Pollution, and

Environmental Health Risks

A number o important studies over the last several years have

linked childrens respiratory health problems with high densities

o vehicular roadway trac. Using modern geographic mapping

techniques, health researchers have concluded that the proximity

o roadways to places where children spend a great deal o their

day experience higher than acceptable levels o exposure to air

pollution.

Presently there are only a ew ways parents could check on airquality in their community, and many o these websites dont

incorporate modern interactive mapping eatures. Department o

Health and Human Services (DHHS) secretary Kathleen Sebelius

recently declared that DHHS needs to make health data more

useul to citizens. Perhaps a good place to begin would be with
http://www.ij-healthgeographics.com/content/pdf/1476-072X-8-53.pdfhttp://webcache.googleusercontent.com/search?q=cache:pVb6nM5tXv0J:www.modernhealthcare.com/article/20100607/NEWS/100609968http://webcache.googleusercontent.com/search?q=cache:pVb6nM5tXv0J:www.modernhealthcare.com/article/20100607/NEWS/100609968http://www.ij-healthgeographics.com/content/pdf/1476-072X-8-53.pdf


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interactive maps that identiy asthma corridors and help parents

keep their kids out o them.

I live in the greater Los Angeles area, well-known or its polluted

air, so I would expect that the best Internet sites would be based

here. But as you will see on the South Coast Air Quality District

site, inormation is or very broad regions and does not revealneighborhood exposures or the exact locations o child care

acilities, schools, parks, and playgrounds. Hourly trac volumes

are also absent. To add these locations and trac volumes does

not seem to be that dicult, and it would certainly improve the

useulness o the map or citizens.

I you dont live in the Los Angeles area, then you might want to

visit the American Lung Association website, where you can enter

your ZIP Code and see a report on the number o people who

will likely have some type o health problem tr iggered by poor airquality.

AirNow, a consortium o international, ederal, state, local, and

media partners, has a website where you can check out your ZIP

Code area and discover hourly air qualitybut be sure to read

the Frequently Asked Questions section. This air quality map

could benet rom more useul, consumer-riendly eatures and

interactive capabilities such as roads, trac volumes, and satellite

imagery.

I the research carried out in Caliornia is relevant to other states

and communities (and it probably is), the discovery that child

careacilities within 600 eet (the length o two ootball elds) o

a major highway (dened as having more than 50,000 vehicles

a day) have more sick kids should be a wake-up call or every

community. The research also suggests that about 7 percent o

all the Caliornia day care acilities and 5 percent o the schools

that children under 12 attend are too close to a busy highway.

While this research certainly inorms citizens, I wonder why no

one has used geographic inormation technology to estimate

exactly how many children might be too close to a busy

highwaynot just where they attend child care orschool but also

where they actually live. Every time I fy over a large urban area, I

The South Coast Air Quality District website oers air quality inormationor very broad regions but does not reveal neighborhood exposures.
http://www3.aqmd.gov/webappl/gisaqi2/VEMap3D.aspxhttp://www.stateoftheair.org/http://www.airnow.gov/index.cfm?action=airnow.pointmapshttp://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.2005.077727http://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.2005.077727http://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.2005.077727http://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.2005.077727http://ehp03.niehs.nih.gov/article/info:doi/10.1289/ehp.6566http://www3.aqmd.gov/webappl/gisaqi2/VEMap3D.aspxhttp://www3.aqmd.gov/webappl/gisaqi2/VEMap3D.aspxhttp://ehp03.niehs.nih.gov/article/info:doi/10.1289/ehp.6566http://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.2005.077727http://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.2005.077727http://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.2005.077727http://www.airnow.gov/index.cfm?action=airnow.pointmapshttp://www.stateoftheair.org/http://www3.aqmd.gov/webappl/gisaqi2/VEMap3D.aspx


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see many houses and apartments very close to (within 600 eet

o) busy highways! I you have ever had a child who had a chronic

respiratory illness with symptoms o wheezing and coughing,

then you know that having 10 million children across the UnitedStates with asthma (about 18 percent o all children under

12 years o age) is unacceptable.

Maybe its time to rethink our approach as to where we build

houses and locate child care acilities, schools, parks, and other

places where a large number o children spend a majority o

their timeawake or asleep. From personal experience, taking

better care o a childs lungs is a ar better investment than

spending money on treating the lielong damage that bad air will

contribute. The window o opportunity is very smallthe rst

12 years o lie!

In translating public health research into inormation that helps

us all make better choices about where we raise our uture

generationour childrenwe will also come to expect more

rom those who measure and report on the quality o our air.
http://ehp03.niehs.nih.gov/article/fetchArticle.action?articleURI=info%3Adoi%2F10.1289%2Fehp.0901232http://ehp03.niehs.nih.gov/article/fetchArticle.action?articleURI=info%3Adoi%2F10.1289%2Fehp.0901232


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23Does the Environment Really Matter to Your Health?GeomedicineGeography and Personal Health August 2012

Does the Environment Really Matter to Your Health?

GIS and Global Health

The use o GIS is rapidly spreading around the world as one o

the most important technologies to help nations address their

most serious health goals including reducing disparity in available

medical services, improving access to services, and preventing

the spread o disease. Striving or ubiquitous health could mean

health everywhere, anytime. I acknowledge that health is on a

continuumone does not arrive at good health accidentally.

Personal health begins beore birth and continues throughout a

persons lie. Access to health and human services has become

one o the major determinants o the degree o health attained.

Multiply one persons health by billions, and this brings us to

global health.

The strength o modern GIS technology extends well beyond

geographically relevant data analysis and powerul data

visualization. It excels as a medium that helps inorm, organize,

and deliver health and human services. GIS supports every web-

based service locator, directions-nding website, and consumer-acing inormation and reerral service sponsored by health

organizations.

As nations strive to protect their citizens rom the threat o

inectious diseases such as legionella, dengue ever, West

Nile virus, tuberculosis, or avian infuenza, GIS has become an

important technology or adding intelligence to existing disease

surveillance systems at the local, regional, and national levels.

GIS technologys ability to author, publish, and share criticalinormation about the spatial dynamics o disease makes it,

without exception, the technology o choice or accelerating the

detection and identication o disease clusters. GIS technologys

capacity to reach beyond geopolitical boundaries makes it highly

desirable in public health emergencies and responses.

The Ministry o Environmental Protection o the Peoples Republico China uses GIS to reveal manuacturing sites.


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GeomedicineGeography and Personal Health August 2012 24Does the Environment Really Matter to Your Health?

As every person is di erent, so too is every community and

nation. However, the various ways that inormation technology is

used seem undamentally parallel. The ways in which GIS is used

by health and human services organizations are more similar thandissimilar; thereore, one o the greatest promises o GIS is its

ability to speak a common language. In my opinion, developing

a common language about health and human services helps

nations move orward.

The adoption o any inormation technology is ultimately a

unction o its ability to produce results such as creating evidence,

identiying inequities, better inorming decision makers, and

aiding more responsive actions and interventions to protecthuman health.

Today, more than 129 (65%) national health ministries located

across every continent use some type o GIS technology. In

developing nations where modern inormation technology is

resource challenged, GIS technology is being deployed in the

orm o specialty epidemiological sotware distributed at low or

no cost to health proessionals through organizations such as the

World Health Organization, Pan-American Health Organization,

and the US Centers or Disease Control and Prevention (CDC).

As GIS technology continues to enjoy wider adoption in health

and human services organizations across all types o government

and private health care organizations, knowledge about our

communitiesespecially how our local environments impact our

personal healthwill command greater attention by community

leaders everywhere. The ability to respond to emergencies and

prepare citizens or disasters, such as pandemics, cannot be

overlooked or underresourced in regard to inormation systems.

Global health begins at home. The obligation o nations to help

citizens have a sae, healthy passage through lie is neither a small

nor simple matter. Dedication by health proessionals in building

eective systems and practices must be supported by evidence

This H1N1 Operational Viewer lets health ocials and the general publictrack infuenza cases.


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and results. It also takes knowledgeable people and progressive

technologies to promote condence in the inormation that is

communicated.

Delivering on the goal o global health requires unrelenting

devotion to leveraging todays knowledge technologies to

mitigate the problems we ace today. GIS will certainly play a

large role in moving communities and their nations orward,

and when we move orward, everyone everywhere has a better

chance to attain the desirable health that is so needed in the

world.

Evaluating Geomedicine

The geomedicine idea has recently been receiving a lot o

attentionat TEDMED 2009, Microsots Health Tech Today, the

Hufngton Post, and elsewhere. This exposure has led to many

interesting and thought-provoking comments about geomedicine

and the larger question o the importance o environment to

health. Id like to address some o the comments and concerns

here.

Some have elt the evidence o relationships between our

environment and human health was marginal, at best, while

others have stressed its importance. One reader mentioned the

vastness o the evidence in the scientic literature about the

harmul eects o environmental contamination on human health,

while others took issue with the notion that our environments are

as important as liestyles or genetics. Several comments warned

that knowing more about the potential hazards o environmental

impacts on health would only promote more lawsuits.

One comment in particular that caused me to finch was a

suggestion that people with limited economic opportunities and

less access to medical care tend to live in less healthy places. This,

i it is really true, would have huge societal implications. Which

This analysis examined the probability o thyroid cancer rates in children inBelarus as a result o the Chernobyl nuclear reactor explosion.
http://www.ted.com/talks/lang/en/bill_davenhall_your_health_depends_on_where_you_live.htmlhttp://www.youtube.com/watch?v=5qxF_RriVd4http://www.huffingtonpost.com/bill-davenhall/http://www.huffingtonpost.com/bill-davenhall/http://www.youtube.com/watch?v=5qxF_RriVd4http://www.ted.com/talks/lang/en/bill_davenhall_your_health_depends_on_where_you_live.html


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comes rstbad health or unhealthy communities? Do you think

that the poor are naturally drawn to less healthy places?

A physician commented that my personal story overreached the

environmental impacts on my health, suggesting, however, that

the idea o creating a place history had merit. Some people

wished or solid evidence (correlations and causation) in what I

had to say. Even the comments that were critical o the strength

o environmental evidence were supportive o the idea that

society should get busy cleaning up known compromised

environments. Much to my surprise, there were many comments

that refected peoples concern over governments role in

watching society too closely and the potential abuse o this type

o inormation or its analysis by health insurance companies and

governments to deny coverage or otherwise limit our economic

opportunities.

It was also suggested that i your physician thinks your symptoms

refect an environmental cause, then he/she would certainly ask

you more about your personal geographic place history. Many

agreed on the value o creating a personal place history, and

many others shared stories where they believed overlooked

environmental actors could potentially explain a personal health

event or condition. One physician said that this idea is an

incredibly commonsense approach [that] could help unveil risk

actors rom your past and potential health issues to look out or.

This doctor suggested that patients should tell their doctor i

they think they have been exposed to a toxic substance. While

I certainly agree with that advice, it is oten what we dont

know and see in and around our environments that is the most

harmul to our health. In general, comments refected a growing

awareness o the potential impact o environmental actors, and

most elt it was smart to tr y to use all the available inormation

when it comes to understanding what makes them sick.

Analysis o Air Pollution by the Brno City Municipality

(Courtesy o ARCDATA Praha, s.r.o.)


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The recent news stories o the identication o a long-term

pediatric cancer cluster in Florida by the US CDC and o the

contaminated well water and soil rom the long-term disposal o

hexavalent chromium in a rural Pennsylvania community by theUS EPA have people worried. One thing these events have in

common is the need to discover the many people who lived near

this contamination long beore it was identied as a potential

threatthus, a compelling need or an accurate personal place

history linked to our electronic medical record.

In my opinion, those who are building electronic health records

supposedly or the benet o patients and health-seeking

consumersmust make sure we have a reliable way to link our

personal place history to the sophisticated electronic health

records they are building now.

The Future of Geomedicine

A key element in the growing acceptance o geomedicine will

be the exploitation o the body o research produced by the

health science community. Also critical will be the ability to

build and organize relevant medical content that links place to

health conditions, risks, and outcomes. For example, research

examining the impact o ambient air quality on cardiovascular

and respiratory disease is under way in many nations o the world,

and research is conrming that a patients health is related to

proximity to high-volume roadways, an idea being examined

using GIS. There is a substantial body o scientic literature that

describes the impact o geographic location on health problems

such as cancer, diabetes, hypertension, and osteoporosis, and

the importance o place is becoming better understood.

A key element o the acceptance o geomedicine by physicians

will be the useulness and accessibility o this body o research.

Also critical is the ability o medical libraries and health research

organizations to make their data holdings accessible over the

Internet. Integrating a patients place history into existing


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electronic medical and personal health records is one o the

principal roles o todays geographic expert system. Just as

the collection o amily medical history helps clinicians look or

certain predispositions to diseases, geographic place will providethe context within which the clinician can assess environmental

actors and make judgments about diagnosis, treatment, and

prognosis.

Much like the capabilities o lab systems to make clinicians aware

o panic values, GIS can provide the same early warnings

to suggest to clinicians environmental actors to be explored.

Geomedicine has the potential to transorm the way physicians

see patients and to provide a more holistic view o the many

hidden actors that oten deeat achieving successul long-term

health outcomes.


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29BibliographyGeomedicineGeography and Personal Health August 2012 29BibliographyGeomedicineGeography and Personal Health August 2012

Bibliography

Artz, Matt. Relating Geography and Health Care:An Interview with Bill Davenhall. GeospatialToday, July 2010.geospatialtoday.com/gst/index.php?option=com

_content&view=article&id=870

Berke, Ethan M. Geographic InormationSystems (GIS): Recognizing the Importance oPlace in Primary Care Research and Practice.Journal o the American Board o Family Medicine,JanuaryFebruary 2010.

http://www.jabm.org/content/23/1/9.ull.pd+html

Conn, Joseph. Data-Driven: HHS Taps intoTreasure Trove o Ino. ModernHealthCare.com,June 7, 2010.http://webcache.googleusercontent.com/search?q=cache:pVb6nM5tXv0J:www.modernhealthcare.com/article/20100607/NEWS/100609968

Davenhall, Bill. Spatial Medicine to BetterHealth. Geospatial Today, March 2007.

esri.com/library/reprints/pds/geospatial-today-health.pd

Davenhall, Bill. Your Health Depends on WhereYou Live. TEDMED 2009.ted.com/talks/bill_davenhall_your_health

_depends_on_where_you_live.html

Davenhall, Bill. Helping Shape Global Health.ArcUser, Winter 2010.esri.com/news/arcuser/0110/global-health.html

Davenhall, Bill. Geomedicine: The Missing Linkin Our Personal Health History. Hufngton Post,February 5, 2010.hufngtonpost.com/bill-davenhall/geomedicine

-the-missing-l_b_451148.html

Davenhall, Bill. GeographyThe Missing VitalSign in Your Physicians Ofce. Hufngton Post,March 11, 2010.hufngtonpost.com/bill-davenhall/geography

----the-missing_b_494479.html

Davenhall, Bill. Does the Environment Matter toYour Health? Hufngton Post, April 14, 2010.hufngtonpost.com/bill-davenhall/does-the

-environment-matt_b_535041.html

Davenhall, Bill. Environmental Health Watch: AreThere Toxins in Your Home? Hufngton Post, May13, 2010.hufngtonpost.com/bill-davenhall/environmental

-health-watc_b_568628.html

Davenhall, Bill. Cancer Maps: The Power o

Geomedicine at Work. Hufngton Post, June 7,2010.hufngtonpost.com/bill-davenhall/environmental

-health-canc_b_599524.html

Davenhall, Bill. Busy Roads, Air Pollution andEnvironmental Health Risks. Hufngton Post,July 24, 2010.hufngtonpost.com/bill-davenhall/environmental

-health_b_653493.html

Davenhall, Bill. Is Your Local Water Supply Sae?Hufngton Post, August 26, 2010.hufngtonpost.com/bill-davenhall/water-quailty

-in-your-med_b_685548.html

Davenhall, Bill. Geomedicine: What Your StreetAddress Can Tell Doctors about Your Health.Hufngton Post, September 28, 2010.hufngtonpost.com/bill-davenhall/your-street

-address-can-i_b_737308.html

Davenhall, Bill. Geomedicine: Using GeographicalInormation Systems to Improve PersonalHealth. Paper submitted or the BridgingPublic Health Inormatics with Personal HealthRecords: Opportunities or Wellness and DiseasePrevention session o the Tenth InternationalConerence on Inormation Technology andApplications in Biomedicine, November 35, 2010.

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-history-explorin_b_779166.html

Davenhall, Bill. Geomedicine Shows Patterns inUS Breast and Prostate Cancer. Hufngton Post,February 7, 2011hufngtonpost.com/bill-davenhall/post_1663_b_817254.html


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Green, Rochelle S.; Svetlana Smorodinsky;Janice J. Kim; Robert McLaughlin; and BartOstro. Proximity o Caliornia Public Schools toBusy Roads. Environmental Health Perspectives,January 2004.http://ehp03.niehs.nih.gov/article/ino:doi/10.1289

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31AcknowledgmentsGeomedicineGeography and Personal Health August 2012

Acknowledgments

Portions o this e-book have been previously published in

Geospatial Today, Hufngton Post, ArcUser, and the Esri Insider

blog and presented at conerences including TEDMED 2009.

About the Author

Bill Davenhall has

worked in the health

and human services

eld since the early

1970s, during which

time he has directed

many dierent

initiatives that involve the progressive use o inormation systems

within health care and human-services delivery organizations.

Davenhall is a requent speaker and writer and is well known as

one o the leading advocates or the use o GIS to help solve the

challenges in health and human services. He earned a masters

degree ocused on medical behavioral science research rom the

University o Kentucky. Davenhall is the global manager o Esris

Health and Human Services Solutions Group at the companys

headquarters in Redlands, Caliornia.

About Esri

Founded in 1969 and the worlds leading GIS sotware vendor,

Esri serves more than 300,000 clients. The health and human

services solutions sector is a community o more than 5,000

licensed users worldwide, housed within over 129 national

health ministries and thousands o community-ocused health

departments, community hospitals, managed health care

programs, and health-related businesses. Esri develops and

supports its sotware through 90 international distributors and

more than than 3,000 associates worldwide.


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Any sotware, documentation, and/or data delivered hereunder is subject to the terms o the License Agreement. The commercial license rights in the License Agreement strictly govern Licensees use, reproduction, or disclosure o the sotware, data, and documentation. In no event shall the US Government acquire greater than RESTRICTED/LIMITED RIGHTS. At a minimum,use, duplication, or disclosure by the US Government is subject to restrictions as set orth in FAR 52.227-14 Alternates I, II, and III (DEC 2007); FAR 52.227-19(b) (DEC 2007) and/or FAR 12.211/12.212 (Commercial Technical Data/Computer Sotware); and DFARS 252.227-7015 (DEC 2011) (Technical Data Commercial Items) and/or DFARS 227.7202 (Commercial Computer

Sotware and Commercial Computer Sotware Documentation), as applicable. Contractor/Manuacturer is Esri, 380 New York Street, Redlands, CA 92373-8100, USA.

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ESRI Geomedicine

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